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Life goes on

October 2012

Published in the October 2012 issue of Today’s Hospitalist

BACK IN DECEMBER, we announced that it was “the end of the world as we know it ” “or, at least, the end of the coding version that we were all used to. The U.S. implementation of the 10th edition of the International Classification of Diseases (ICD-10) was looming, and havoc for hospitals and physicians was widely anticipated.

Like other modern apocalypses “that whole Mayan thing “coding Armageddon didn’t happen. In the case of ICD-10, however, the prophecy wasn’t bogus; the implementation date simply changed. The Centers for Medicare and Medicaid Services, in effect, kicked the coding manual and upgrade down the road, postponing all those headaches for another day.

The International Classification of Diseases, which was initially maintained by the World Health Organization (WHO), has been around since the late 1940s. It provides a vast taxonomy of diseases and other billable stuff.

Obtuse descriptions of diagnoses “”diabetes mellitus with ketoacidosis type 1 not stated as uncontrolled” “get compressed into tidy little medical ZIP codes (250.11). Your coder sends these strings of digits (and occasional letters) to insurance companies and, with a little luck, you eventually get paid accordingly.

The 9th edition of ICD hit the scene in the 1970s, and the U.S. has been stuck there ever since. The American Medical Association (AMA) became its official keeper when WHO moved onto ICD-10 in the 1990s. WHO is presently working on ICD-11, which is anticipated in 2015.

Although the AMA keeps updating ICD-9 (it’s hardly “international” at this point), there are inherent limitations imposed by the rubric itself. ICD-10, which has a completely different structure, is more granular and consistent with contemporary medical practice. It’s also much more comprehensive, with approximately 70,000 codes rather than ICD-9’s 14,000.

And the differences between the two versions are in type, not mere degrees: Think credit card calculator (ICD-9) vs. iPhone (ICD-10).

Most first-world countries rolled out ICD-10 long ago. Canada, for example, implemented it in 2001, while the U.K. got onboard with ICD-10 as early as 1995.

The U.S., by comparison, has struggled. The Department of Health and Human Services (HHS), keeper of Medicare, has set targets and moved them several times. In 2008, the HHS was shooting for a go-live for ICD-10 in October 2011. In 2009, it bumped it up to October 2013.

And just this summer, the HHS pushed it back again, this time to October 2014. That was in part a response to some pretty intense lobbying for a delay from many health care groups, including the American Hospital Association and the AMA.

Critics opposed to the 2013 implementation date insisted that between 25% and 50% of providers wouldn’t be ready. They also claimed that small community hospitals would be at a particular disadvantage.

That seems to bear out the famous theory introduced by Everett Rogers, PhD, a writer and communication scholar, which he said describes “the diffusion of innovations.” According to that theory, the first 2.5% of adopters are “innovators,” the next 13.5% are “early adopters” and so on. The last 16% are considered “laggards.”

If Dr. Rogers were still alive today (he died in 2004), he’d need to come up with another category to describe the truly hopeless. We’d suggest “recalcitrants,” “frowards” or maybe “the perennially contumacious.”

Now what?
So will we ever actually use ICD-10?

If the AMA gets its way, probably not. In a letter to the HHS, the AMA asked the department to postpone implementation until at least 2015. In the interim, the medical society suggested that “all relevant stakeholders … assess whether an alternative code set approach is more appropriate than the full implementation of ICD-10.” The AMA further advised that “if stakeholders cannot reach consensus on this matter during this two-year delay period, then the move to ICD-10 should be postponed indefinitely.”

Despite all of this uncertainty, health care organizations need to keep playing along. The HHS has noted that the current “implementation date is not flexible” and that it will reject claims from entities that fail to comply.

That, of course, remains to be seen. Here at HealthEast, which has four hospitals and lots of clinics, a transition team has been working on all the necessary issues so we can eventually throw the switch. Labor has been divided among five committees:

    • steering, with inpatient and outpatient representation;
    • revenue cycle;
    • education and training;
    • clinical documentation improvement; and
    • data users (analytics).

The team has continued to soldier on, despite changes in the HHS timeline. The education and training committee, for example, is trying to figure out which employees need training sessions and when these sessions should occur.

HealthEast already has four certified ICD-10 trainers for this effort. These uber coders will definitely have their hands full. The HHS estimates that “experienced inpatient coders will require 50 hours of additional training to code in ICD-10.”

As you can imagine, all of this work, which is a speculative investment, is very costly. But Medicare is too big to ignore, so health care organizations keep preparing and spending.

In the trenches
For hospitalists, in the meantime, life goes on. We’ll continue to describe the most advanced medical care on the planet with a dead language until someone tells us otherwise.

David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. You can learn more about him and his work at www.davidfrenz.com. Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care System.